Recheck

Recheck - 10/15/2023 by Dr. Emily Carter for Dr. Thomas Kelly. **Presentation** Max, a 5-year-old Labrador Retriever, presented for a recheck following a recent diagnosis of gastroenteritis. **Recent targeted history** - No significant changes since the last visit - Eating habits have improved, now eating twice daily - Current diet: Hill's Prescription Diet i/d - Drinking habits: normal - Urination habits: normal - Defecation habits: stools are firmer - Absence of vomiting or diarrhoea - Absence of cough or sneezing - Fasting status for the day: fasted **Medications currently being given** - Metronidazole, 250 mg, twice daily, last dose given at 8 AM **Targeted physical examination** - Current weight: 30 kg, stable - Body condition score: 5/9 - Musculature assessment: normal - Thoracic auscultation findings: clear - Abdominal palpation findings: mild tenderness - Vital signs: heart rate 90 bpm, respiratory rate 20 bpm, mucous membrane color pink, body temperature 101.5°F **Diagnostic tests performed today** - Fecal analysis: no parasites detected **Diagnostic handling** - Fecal sample processed in-house **Procedures performed today** - None **Problem list** - Gastroenteritis **Assessment** Max is showing improvement in his condition with firmer stools and no vomiting. Gastroenteritis is suspected to be resolving. Labrador Retrievers are not specifically predisposed to this condition, but dietary indiscretion is common. Recurrence risk is low with proper dietary management. **Plan (admitted to hospital, going home 10/15/2023)** - Discharge status: going home - New treatment plan: continue current diet and medication - Metronidazole, 250 mg, twice daily, next dose due at 8 PM **Communication and estimate** - Discussed Max's progress with owner at 10 AM via phone. Owner is pleased with improvement and has no concerns. - Estimate for today's visit discussed and agreed upon. - Recommended continued monitoring of diet and stool consistency. **Short term plan and instructions** - Pending results: none - Recheck requirements: follow-up in 2 weeks - Fasting instructions for future visits: fast 12 hours prior **Long term plan** - Recheck schedule: every 6 months for wellness - Recurrence risk and prevention recommendations: avoid dietary indiscretion - Dietary recommendations: continue Hill's Prescription Diet i/d - Medication recommendations: complete current course - Water intake recommendations: ensure fresh water is always available - Refractory case management: monitor for any signs of recurrence - Monitoring plan and frequency: observe stool consistency daily